text:
ART indicates antiretroviral therapy; TB, tuberculosis.aAdditional censoring at each duration of follow-up was due to the patients not being in care for long enough at the close of the study.
CI indicates confidence interval; TB, tuberculosis.aAdjusted for age, sex, and baseline CD4 cell count. The adjusted odds ratios and 95% CIs were rounded to 1 decimal.bCombined odds ratios were calculated with generalized estimating equation and an exchangeable correlation matrix.
ART indicates antiretroviral therapy; CI, confidence interval; HR, hazard ratio; TB, tuberculosis. Error bars indicate 95% CIs. Adjusted for age, sex, and baseline CD4 cell count.
ART indicates antiretroviral therapy; CI, confidence interval; HR, hazard ratio; TB, tuberculosis. Error bars indicate 95% CIs.aAdjusted for age, sex, baseline CD4 cell count, and year of ART initiation.bAdjusted for age, sex, and baseline CD4 cell count.
ART indicates antiretroviral therapy; CI, confidence interval; HR, hazard ratio. Error bars indicate 95% CIs. Adjusted for age, sex, and baseline CD4 cell count.
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Boulle A, Van Cutsem G, Cohen K, et al. Outcomes of Nevirapine- and Efavirenz-Based Antiretroviral Therapy When Coadministered With Rifampicin-Based Antitubercular Therapy. JAMA. 2008;300(5):530–539. doi:10.1001/jama.300.5.530
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Author Affiliations: School of Public Health and Family Medicine (Drs Boulle and Coetzee and Ms Hilderbrand), Division of Clinical Pharmacology, Department of Medicine (Drs Cohen and Maartens), University of Cape Town, Médecins Sans Frontières (Drs Van Cutsem and Goemaere and Ms Hilderbrand), and Site B Community Health Centre, Department of Health, Provincial Government of the Western Cape (Drs Mathee and Abrahams), Cape Town, South Africa.
Context Rifampicin-based antitubercular therapy reduces the plasma concentrations of nevirapine and efavirenz. The virological consequences of these interactions are not well described.
Objective To assess the effectiveness and tolerability of concomitant efavirenz- or nevirapine-based combination antiretroviral therapy and rifampicin-based antitubercular therapy.
Design, Setting, and Participants Cohort analysis of prospectively collected routine clinical data in a community–based South African antiretroviral treatment program. Antiretroviral treatment-naive adults enrolled between May 2001 and June 2006 were included in the analysis, and were followed up until the end of 2006.
Interventions Patients starting antiretroviral therapy with or without concurrent antitubercular therapy received either efavirenz or nevirapine at standard doses. Patients developing tuberculosis while taking antiretroviral therapy that included nevirapine were either changed to efavirenz or continued taking nevirapine.
Main Outcome Measures Viral load of 400 copies/mL or more after 6, 12, and 18 months of antiretroviral therapy; time to the first viral load of 400 copies/mL or more; time to confirmed virological failure (2 consecutive values ≥5000 copies/mL); time to death; and time to treatment-limiting toxicity were assessed.
Results The analysis included 2035 individuals who started antiretroviral therapy with efavirenz (1074 with concurrent tuberculosis) and 1935 with nevirapine (209 with concurrent tuberculosis). There were no differences in time to death or substitution of either antiretroviral drug for toxicity with and without concurrent tuberculosis. Patients starting nevirapine with concurrent tuberculosis were at a higher risk of elevated viral load most notably at 6 months (16.3%; 95% confidence interval [CI], 10.6%-23.5%) than those without tuberculosis (8.3%; 95% CI, 6.7%-10.0%; adjusted odds ratio [OR], 2.1; 95% CI, 1.2-3.4; and in the combined estimate, adjusted OR, 1.7; 95% CI, 1.2-2.6). In the time-to-event analysis of confirmed virological failure (2 consecutive values of ≥5000 copies/mL), patients starting nevirapine with concurrent tuberculosis developed virological failure sooner (adjusted hazard ratio [HR] 2.2; 95% CI, 1.3-3.7). There were no differences between patients starting efavirenz with and without concurrent tuberculosis (adjusted OR, 1.1; 95% CI, 0.8-1.5 [combined estimate] and adjusted HR, 1.1; 95% CI, 0.6-2.0, respectively). There was no difference in time to virological rebound in patients free of tuberculosis and those developing tuberculosis during follow-up while taking nevirapine (adjusted HR, 1.0; 95% CI, 0.5-2.0) or efavirenz (adjusted HR, 0.8; 95% CI, 0.4-1.7).
Conclusion In this cohort study, virological outcomes were inferior when nevirapine-based antiretroviral therapy was commenced while taking antitubercular treatment (vs without concurrent tuberculosis) but comparable when starting efavirenz-based antiretroviral therapy (vs without concurrent tuberculosis) or when tuberculosis developed while taking established nevirapine- or efavirenz-based therapies.
Antiretroviral therapy (ART) programs are rapidly being scaled up in resource-limited countries, where tuberculosis is the most common opportunistic infection.1 Combination ART is frequently initiated when patients are being treated for tuberculosis.2,3 Although ART reduces tuberculosis incidence, tuberculosis continues to occur at considerably higher rates than in individuals who are not infected with human immunodeficiency virus (HIV).1-4 Coadministration of ART and antitubercular therapy may be complicated by shared toxicity, notably hepatotoxicity,5 or by adverse drug interactions. Rifampicin is a potent inducer of cytochrome P450 enzymes, which metabolize many drugs including nonnucleoside reverse transcriptase inhibitor (NNRTI) antiretroviral agents. The NNRTIs are recommended as components of initial combination ART regimens in the public health approach advocated by the World Health Organization (WHO).6
Of the 2 available NNRTIs, efavirenz is preferred for coadministration with rifampicin6,7 because the reduction in the concentration of efavirenz is more modest, efavirenz has a lower risk of hepatotoxicity, and there are several studies showing good ART outcomes with efavirenz.8,9 Some experts recommend increasing the dose of efavirenz when coadministered with rifampicin,6 but evidence, including data from a randomized controlled trial,10 suggests that standard doses are adequate (although there are concerns that there are insufficient data on patients weighing more than 60 kg).7
Nevirapine (often in fixed-dose combination formulations) is the most widely used NNRTI in resource-limited countries because it is much cheaper than efavirenz and, unlike efavirenz, is suitable for women of childbearing potential because it is not a known teratogen. In many countries, it is the only available NNRTI. Pharmacokinetic studies show a more significant reduction in plasma nevirapine concentrations (20%-55% reduction in serum concentrations or the area under the curve) compared with efavirenz when coadministered at standard doses with rifampicin.9,11-16 Nevirapine has a higher risk of hepatotoxicity than efavirenz, although only a small proportion of patients develop clinical hepatitis.17-19 There are 3 small published studies (32 patients from Spain20 and 70 patients21 and 111 patients from Thailand22) that suggest that nevirapine can be safely and effectively coadministered with rifampicin. However, the findings from the Thai studies may not be generalizable to other populations due to ethnic differences in drug effects and the low body weight of the patients, and the Spanish study was retrospective without a comparison group.
Thus a need for more studies exists, particularly from Africa where approximately 85% of HIV-associated cases of tuberculosis occur.4 Our primary objective was therefore to assess the virological outcomes of concomitant efavirenz- or nevirapine-based combination ART and rifampicin-based antitubercular therapy in a cohort of South African patients from a public sector ART program established in 2001.23
This study was conducted at 3 community health centers in the Cape Town township of Khayelitsha, where ART has been available since May 2001, with the number of patients starting ART increasing dramatically in recent years. ART-naive individuals enrolled between May 2001 and June 2006 were included in the analysis and were followed up until the end of 2006. The community of 400 000 inhabitants has an extremely high burden of both HIV and tuberculosis, with antenatal HIV seroprevalence of more than 30%,23,24 and tuberculosis case-finding exceeding 1500 per 100 000 annually.2 This government program has been supported by Médecins Sans Frontières since inception.
The cohort received approval in 2005 from the University of Cape Town ethics committee for analyses (including those with a view to scientific publication) based on anonymized routine clinical data without requiring informed consent. All data in this analysis were anonymized and had been collected as part of the routine standard of care intervention.
Patients were referred to the dedicated HIV services within these community health centers from local clinics and hospitals, as well as from the tuberculosis services and the prevention of mother-to-child transmission program. Once referred, patients accessed treatment based on clinical eligibility, treatment readiness, and clinical severity. Race is not routinely measured as part of clinical or administrative data, but the study site is located in a township in which residents are of black African or mixed ancestry, which describes the patients represented in analyses herein. Women who had been exposed through a regimen intended to prevent mother-to-child transmission to short-course zidovudine or peripartum nevirapine25 were offered the same first-line ART as other women with and without concurrent tuberculosis.
Antiretroviral drugs were provided weekly or fortnightly for the first 2 months of ART, then monthly until the first suppressed viral load, and thereafter either monthly or bimonthly. Patients were seen by a nurse or physician at each follow-up visit and either received the drugs during the consultation or from a dedicated dispensing room immediately after the consultation. Patients were all provided with weekly pillboxes.
There is a structured adherence promotion program at the antiretroviral clinics, which has previously been described.26 Adherence is assessed during consultations by pill counts and self-report, especially shortly after initiation of ART and if patients default or experience virological failure. Quantitatively, adherence is indirectly reflected by viral load outcomes and retention in care.
The first-line ART regimen has always consisted of an NNRTI (either efavirenz or nevirapine) together with 2 nucleoside reverse transcriptase inhibitors. Guidelines in use strongly recommended prescribing efavirenz with rifampicin-based antitubercular therapy until 2004 when provincial guidelines changed to allow clinicians to select either nevirapine or efavirenz.27 Thereafter, clinical practice in the choice of NNRTI with antitubercular therapy varied, with some clinicians continuing to prescribe efavirenz while others prescribed nevirapine.
Standard doses of both efavirenz (600 mg daily) and nevirapine (lead-in dose of 200 mg daily for 2 weeks followed by 200 mg every 12 hours) were used with concurrent tuberculosis treatment in keeping with provincial, national, and international guidelines.6,27,28 The clinical protocols provide for monitoring of viral load and CD4 cell count every 6 months. Baseline viral loads are no longer universally drawn in treatment-naive adults. Patients are deemed eligible for ART when their CD4 cell count approaches or falls below 200 cells/μL or when they have a WHO clinical stage IV illness other than extrapulmonary tuberculosis. The local definition of virological failure is 2 consecutive viral load measurements of 5000 copies/mL or higher. Viral load tests were performed by the National Health Laboratory Service, initially using the NucliSens HIV-1 QT assay and later the NucliSens EasyQ HIV-1 assay (bioMérieux, Boxtel, the Netherlands).
Tuberculosis medication was provided daily (5 days a week) at 8 dedicated tuberculosis clinics in the community and was directly observed either by clinic staff or by trained community-based tuberculosis treatment supporters. Fixed-dose combinations are used to promote adherence (for new tuberculosis cases, these comprise rifampicin, pyrazinamide, isoniazid, and ethambutol for 2 months, followed by rifampicin and isoniazid for 4 months). Tuberculosis was diagnosed according to standard guidelines, with either positive microscopy for acid-fast bacilli, a positive culture of Mycobacterium tuberculosis, or after the application of an algorithm for identifying smear-negative tuberculosis.29
Routine clinical data have been prospectively entered into an electronic patient information system, which is regularly validated for accuracy and completeness. In this analysis, all treatment-naive individuals 14 years or older, with a CD4 cell count lower than 250 cells/μL, who started receiving NNRTI-based ART by June 30, 2006, were included. Patients were excluded if they had concurrent tuberculosis at the time that they started ART, but subsequently discontinued tuberculosis therapy within 14 days of starting ART. The remaining patients were classified into 4 groups based on whether ART initiation overlapped with concurrent treatment for tuberculosis and based on which NNRTI was part of their starting ART regimen (Figure 1). Patients were followed up until the earliest of the following possibilities: loss to the program (death, lost to follow-up, transferred out); interruption of ART therapy for any reason; substitution of the initial NNRTI due to toxicity or contraindications (eg, efavirenz changed to nevirapine in pregnancy); starting tuberculosis treatment due to a subsequent diagnosis; or the last visit prior to December 31, 2006. Patients were classified as lost to follow-up after 6 months without a visit to the service. Viral loads were classified as 6-, 12-, or 18-month values based on the duration closest to the actual dates of the test, provided the test was performed within 3 months of the designated duration.
The analysis was conducted between October 2007 and February 2008. Baseline characteristics were described as medians with interquartile ranges for continuous variables and as proportions with exact binomial confidence intervals (CIs) for categorical variables, compared between groups, respectively, through rank sum and χ2 statistics.
The proportions of patients with viral loads of 400 copies/mL or more were calculated at each duration in each of the 4 groups (Figure 1). The odds of a value at or higher than this threshold in patients who were receiving concurrent tuberculosis treatment when starting ART were compared with those who were not, in separate multivariate logistic regression models at each duration for each NNRTI. Pooled odds ratios (ORs) across all durations were additionally determined for each NNRTI and for all 4 groups together with generalized estimating equation repeated-measures analyses accounting for intraindividual correlation through an exchangeable correlation matrix.
For all multivariate models, variables were included based on a priori considerations, if they were themselves associated with the outcome or if they changed the other associations in the model.
Kaplan-Meier failure estimates were determined comparing the 2 tuberculosis exposure groups receiving each NNRTI for time to death, time to NNRTI substitution due to toxicity, time to the first viral load at the threshold of 400 copies/mL or more (restricted to values beyond 30 days of follow-up), time to loss to follow-up, and time to virological failure as defined above. In the analysis of time to death, patients were not censored with subsequent tuberculosis episodes or with changes or interruptions to the NNRTI. In the analysis of time to treatment-limiting toxicity, patients starting ART with TB were censored at the end of the initial tuberculosis episode. Log-rank statistics and adjusted hazard ratios (HRs) from Cox proportional hazard models were determined for each comparison. The proportional hazards assumptions were validated for the Cox models based on Schoenfeld residuals. The CD4 cell count changes relative to baseline were compared at 18 months in separate multivariate linear regression models for each NNRTI.
A second analysis was performed in patients who did not have tuberculosis at the start of ART, in which the time to virological rebound was determined from the time of the first viral load lower than 400 copies/mL. Concurrent tuberculosis treatment as a result of incident tuberculosis during follow-up was included as a time-varying exposure in both Kaplan-Meier estimates and multivariate Cox proportional hazard models. Patients developing tuberculosis remained in this exposure group even if they were followed up beyond the end of the tuberculosis treatment episode. Follow-up was censored in the same way as in the first analysis, except in the case of incident tuberculosis whereby patients were censored if a second episode of tuberculosis occurred during follow-up.
Using the 6-month follow-up duration, the 141 and 1126 patients assessed who started nevirapine-based ART with or without concurrent antitubercular therapy would ensure 88% power to detect a 10% decline in viral load suppression in the group receiving concurrent tuberculosis treatment, assuming a 90% suppression in the reference group (α = .05)
The analysis was conducted using Stata statistical software, 10.0 (StataCorp Inc, College Station, Texas). In each analysis, only observations with complete data on the outcomes and covariates were used, while the completeness of both the main outcome and covariate data are reported (Figure 1 and Table 1, respectively). All statistical tests were 2-sided.
The proportion of patients starting ART while receiving concurrent tuberculosis therapy increased from 21% (17 of 80) in 2001 to 40% (439 of 1099) in 2006. Since 2004, the majority of patients initiated nevirapine-based ART, although in patients with concurrent tuberculosis, efavirenz use has still predominated.
Of 4117 individuals who met the initial inclusion criteria, 2687 were not receiving tuberculosis treatment at the start of therapy (Figure 1). Of the remaining 1430 who started ART while receiving concurrent tuberculosis therapy, 249 started taking nevirapine-based ART and 1181 started taking efavirenz-based ART. Of these, 209 and 1074 patients, respectively, had overlapping treatment for at least 14 days. Overall, in all groups at all durations of follow-up, between 83% and 96% of patients who were eligible for virological assessment and inclusion in the analysis were assessed.
Patients with concurrent tuberculosis were compared between NNRTI groups at the start of ART (Table 1) and were similar with respect to age, baseline viral load where available, weight (median of 56 kg in both groups with concurrent tuberculosis), alanine aminotransferase where available, and the proportion with extrapulmonary tuberculosis. Patients with tuberculosis initiating nevirapine had a slightly higher CD4 cell count (80 vs 61 cells/μL, P = .002) and had been receiving tuberculosis therapy for slightly longer than those initiating efavirenz (87 vs 73 days, P < .001). They were also more likely to be women (73.7% vs 62.1%, P < .001 [because efavirenz is teratogenic, it is often avoided in women of childbearing potential]), less likely to have started taking zidovudine (4.3% vs 14.4%, P < .001), and were less likely to have a stage IV–defining illness (55.0% vs 58.1%, P = .002). Findings in the same directions were observed comparing baseline characteristics between NNRTI groups without concurrent tuberculosis (Table 1), except that patients initiating efavirenz were older and had higher baseline aminotransferase values when available.
Overall, the proportion of patients with elevated viral loads was lowest at 6 months while taking ART in all 4 groups (Figure 2). There was no discernable difference in this measure based on baseline tuberculosis therapy status in patients initiating efavirenz (combined adjusted OR, 1.1; 95% CI, 0.8-1.5). However, a higher proportion of patients initiating nevirapine with initial concurrent tuberculosis had elevated viral loads during follow-up than those without concurrent tuberculosis. This was most notable at 6 months (16.3%; 95% CI, 10.6%-23.5% vs 8.3%; 95% CI, 6.7%-10.0%; adjusted OR, 2.1; 95% CI, 1.2-3.4), and in the combined estimate (adjusted OR, 1.7; 95% CI, 1.2-2.6).
A model combining all the groups together demonstrated clearly the inferior virological outcomes (failure to suppress viral load) in the group starting to take both nevirapine and tuberculosis treatment relative to the efavirenz groups (eg, adjusted OR, 3.2; 95% CI, 2.0-5.2 for the group initiating nevirapine and tuberculosis treatment vs the group initiating efavirenz without concurrent tuberculosis at the start of ART, Table 2). The outcomes associated with receiving nevirapine were inferior even without concurrent tuberculosis (adjusted OR, 1.6; 95% CI, 1.1-2.2 for the group initiating nevirapine without concurrent tuberculosis vs the group initiating efavirenz without concurrent tuberculosis). Age younger than 30 years, a low baseline CD4 cell count, and increasing baseline weight were independently associated with failure to suppress viral load in this model. The use of zidovudine over stavudine in the starting regimen was not associated with the outcome; therefore, this was not included in the final model. We found little evidence for interactions between the NNRTI used or concurrent tuberculosis and any of the other exposure variables in the model (all P values >.05 [likelihood ratio test]). In alternate models that included available baseline viral load data, this was independently associated with failure to suppress subsequent viral loads (adjusted OR, 1.3 for each log10 increase in the baseline value, 95% CI, 1.1-1.6) and did not confound the associations between this outcome—choice of NNRTI—and concomitant tuberculosis.
The time-to-event analysis of failure to suppress viral load (Figure 3A) provided adjusted HR estimates consistent with the pooled adjusted OR estimate above (for nevirapine, adjusted HR, 1.4; 95% CI, 1.0-1.9; for efavirenz, adjusted HR, 0.9; 95% CI, 0.7-1.1). The difference in the case of receiving nevirapine with and without concurrent tuberculosis treatment was more marked when assessing time to confirmed virological failure (adjusted HR, 2.2; 95% CI, 1.3-3.7; Figure 3B). Concurrent tuberculosis treatment was not associated with time to confirmed virological failure in patients starting efavirenz-based ART (adjusted HR, 1.1; 95% CI, 0.6-2.0).
In comparing other outcomes, there was no difference after adjustment between the groups receiving tuberculosis treatment vs those without concurrent tuberculosis for each NNRTI in regard to mortality (adjusted HR for nevirapine, 0.9; 95% CI, 0.5-1.8; adjusted HR for efavirenz, 0.8; 95% CI, 0.5-1.1; Figure 4A), or in regard to time to toxicity-mediated NNRTI substitution (adjusted HR for nevirapine, 1.5; 95% CI, 0.8-2.8; adjusted HR for efavirenz, 0.9; 95% CI, 0.4-2.0; Figure 4B). In patients without concurrent tuberculosis, those patients receiving nevirapine were more likely to have their therapy substituted due to toxicity compared with those receiving efavirenz (cumulative proportion receiving nevirapine having treatment substitution by 6 months, 4.9%; 95% CI, 3.9%-6.1% vs 1.4%; 95% CI, 0.8%-2.4% in the case of efavirenz).
For both nevirapine and efavirenz, concurrent tuberculosis treatment at the start of ART was associated with an additional gain of 29 cells/μL in CD4 cell count at 18 months compared with baseline, adjusted for age, sex, and baseline CD4 cell count (95% CI, 1-56 for nevirapine; 95% CI, 6-51 for efavirenz), in comparison with patients taking nevirapine and efavirenz without tuberculosis.
In the 4 groups combined, viral load suppression to less than 400 copies/mL was 92.4% (95% CI, 91.3%-93.4%) at 6 months, 89.3% (95% CI, 87.8%-90.7%) at 12 months, and 86.8% (95% CI, 84.6%-88.8%) at 18 months of ART. Cumulative loss to follow-up was 5.6% (95% CI, 4.4%-7.5%) at 24 months of ART and was comparable between the 4 groups.
The final analysis compared the time to virological rebound between patients remaining free of tuberculosis during follow-up and those who were initially free of tuberculosis but subsequently started tuberculosis treatment due to a new tuberculosis episode (Figure 5). There was no difference in time to rebound between the groups among those who did and did not experience incident tuberculosis receiving either NNRTI (adjusted HR, 1.0; 95% CI, 0.5-2.0 for nevirapine; adjusted HR, 0.8; 95% CI, 0.4-1.7 for efavirenz).
Coadministered rifampicin-based antitubercular therapy at ART initiation resulted in higher probabilities of an elevated viral load or virological failure in the first 2 years of therapy in patients taking nevirapine-based ART but not in patients who started efavirenz-based ART. In spite of these differences, virological outcomes were good, with 80% of patients in the initial nevirapine-rifampicin group being virologically suppressed at 18 months' duration of ART. For both NNRTIs, incident tuberculosis during follow-up did not result in an increased risk of virological rebound.
The differential findings between the group starting nevirapine with prevalent tuberculosis and those developing tuberculosis once already established on ART could be the result of the limited power of the latter analysis to detect a difference due to the inclusion of fewer patients with incident tuberculosis. An alternative explanation, however, is a drug interaction mediated by rifampicin during the lead-in dosing phase of nevirapine. A 2-week lead-in period of once daily instead of twice daily dosing is recommended to allow for the autoinduction of the cytochrome P450 enzyme system by nevirapine. In patients taking rifampicin, the system is however already induced. A recent Malawian study30 found that 59% of patients coinfected with HIV and tuberculosis had subtherapeutic nevirapine concentrations during the lead-in dosing phase. A Thai study that compared patients initiating efavirenz-based or nevirapine-based ART with concurrent tuberculosis reported an OR between these groups for achieving a viral load lower than 50 copies/mL at 48 weeks of 0.590 (95% CI, 0.302-1.153)22 but was based on smaller numbers of patients.
The published literature on the virological efficacy of standard doses of NNRTI-based ART coadministered with rifampicin is sparse, but the data are generally encouraging. The existing studies have, however, been limited by small sample sizes8,20,21,30,31 or by the failure to include a control group.30,31
Key strengths of our study include the large sample size of patients starting ART, a good follow-up rate, and the assessment of virological responses by failure to suppress, rebound, and confirmed failure. Adherence in this cohort, as best as can be measured, was generally good as reflected by virological suppression and comparably low rates of loss to follow-up between groups. Thus, it seems unlikely that differences in adherence account for the differences that we found in virological outcomes.
The study has a number of limitations. First, although we demonstrated inferior virological outcomes in patients starting ART with prevalent tuberculosis and nevirapine, we were unable to demonstrate differences in survival or CD4 cell count change. Interpretation is therefore based on the premise that virological failure would eventually result in clinical failure. Second, although we believe that the decision to use nevirapine with rifampicin in this study has been a systematic one rather than by clinical indication, as an observational study, there remains the possibility of residual confounding by indication. In comparing the clinical characteristics of patients with tuberculosis when starting ART, it would appear that if anything, the sicker coinfected patients with a higher risk of virological failure were more likely to start efavirenz-based ART as evidenced by a lower median baseline CD4 cell count, a higher probability of having AIDS, and a shorter duration of tuberculosis treatment. Third, the detection limit of the viral load assay in our study was 400 copies/mL, whereas virological suppression to values 10-fold lower than this are required for long-term suppression.32 Finally, it was not possible with the available data to compare tuberculosis outcomes between the groups studied.
The association with increased weight and failure to suppress viral load in the combined model underlines the importance of weight in assessing the adequacy of NNRTI dosing. In addition to concerns about subtherapeutic dosing, at the other end of the spectrum, a low baseline weight has been associated with NNRTI toxicity.19 More detailed analyses of associations between weight and virological outcomes and toxicity in patients on NNRTIs are required in this setting.
For both NNRTIs, CD4 cell count increases were higher in patients who commenced ART with prevalent tuberculosis compared with patients without tuberculosis. The likely explanation for this is the additive effect of the CD4 cell count increase observed when tuberculosis is treated in the absence of ART.33 This confounds any attempt to determine the effect of the observed differences in virological outcomes on CD4 cell count changes.
The association between nevirapine use and failure to suppress viral load in patients without concurrent tuberculosis is consistent with data from both randomized controlled trials18 and a number of observational studies.34-36 The more rapid development of treatment-limiting toxicity in patients receiving nevirapine compared with those receiving efavirenz, irrespective of tuberculosis treatment, has previously been described together with a characterization of the toxicities involved.19
Nonnucleoside reverse transcriptase inhibitor–based ART is tolerable and effective when coadministered with rifampicin-containing antitubercular therapy. Probabilities of elevated viral loads during follow-up and confirmed virological failure are higher in patients with prevalent tuberculosis starting nevirapine-based ART. Given the continued reliance on nevirapine-containing ART regimens in Africa, together with the important role tuberculosis services play as an entry point for ART, further prospective studies exploring this outcome are warranted. One of the most striking aspects of our study was the demonstration that 40% of patients starting ART in recent years have concurrent tuberculosis, underscoring the public health importance of improving affordable treatment options for patients infected with HIV and tuberculosis in this setting.
Corresponding Author: Andrew Boulle, MBChB, MSc, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa (firstname.lastname@example.com).
Author Contributions: Dr Boulle had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Boulle, Van Cutsem, Cohen, Hilderbrand, Goemaere, Coetzee, Maartens.
Acquisition of data: Boulle, Van Cutsem, Hilderbrand, Mathee, Abrahams, Goemaere, Coetzee.
Analysis and interpretation of data: Boulle, Van Cutsem, Cohen.
Drafting of the manuscript: Boulle, Van Cutsem, Abrahams, Maartens.
Critical revision of the manuscript for important intellectual content: Van Cutsem, Cohen, Hilderbrand, Mathee, Goemaere, Coetzee.
Statistical analysis: Boulle, Van Cutsem, Cohen.
Obtained funding: Hilderbrand, Goemaere, Coetzee.
Administrative, technical, or material support: Van Cutsem, Hilderbrand, Mathee, Abrahams, Goemaere.
Study supervision: Van Cutsem, Coetzee, Maartens.
Financial Disclosures: Dr Maartens reported receiving a speakers honorarium from Merck, Sharp & Dohme South Africa. No other authors reported disclosures.
Funding/Support: No specific funding was received for this analysis. The clinical services were funded by the Provincial Government of the Western Cape, the Global Fund for AIDS, Tuberculosis and Malaria, and Médecins Sans Frontières.
Role of the Sponsor: None of these organizations were involved in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript.
Previous Presentation: This study was presented in part at the 38th Union World Conference on Lung Health; November 8-12, 2007; Cape Town, South Africa.
Additional Contributions: We thank all patients and staff in the Ubuntu HIV/TB clinic, and the HIV services at Nolungile and Michael Mapongwane community health centers in Khayelitsha, Cape Town. We also thank all other clinical, management, and support staff who have assisted the Khayelitsha HIV services from the University of Cape Town, Médecins Sans Frontières, the City of Cape Town, and the Provincial Government of the Western Cape.
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text:
Kanye's S.F. proposal to Kim Kardashian
SAN FRANCISCO — Kanye West gave Kim Kardashian a big 33rd birthday surprise Monday night at AT&T Park: a proposal of marriage. When the couple stepped out on the field, the screen that usually shows hits, runs and errors read "Please Marry Me" instead.
Kardashian, not a coy woman, gave an immediate yes as 50 musicians played songs including West's "Knock Me Down." Fireworks and candle-like flames were shot into the night sky, and West presented her with a 15-carat diamond ring.
West is to give a series of concerts in the Bay Area beginning Tuesday in San Jose. A bunch of friends and family members were on hand, and they ran out of the dugout when the proposal was accepted. The would-be groom is said to have asked his future mother-in-law, Kris Jenner, for permission to take the hand of his lady. Permission was granted.
Plans had been made in deep secrecy, but a number of entertainment sites seemed pre-primed. Entertainment Weekly had reported West as saying he was ready to marry Kardashian, and stories about the actual proposal were online within minutes.
Leah Garchik is a San Francisco Chronicle columnist. E-mail: email@example.com Twitter:@leahgarchik

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Two reality singing shows — NBC's The Voice and Fox's The X Factor — turned the competition over to America this week, with viewer votes determining which contestants would be safe and which ones would have to sing to stay on the show.
On The X Factor, the singer who eventually got sent home was Jason Brock, an openly gay performer (he never said so explicitly, but made a show of pinching host Mario Lopez's rear end during the first live show and dedicated his final performance to "the gays and Japan") whose repertoire on the show included Jennifer Lopez's "Dance Again" and Bonnie Tyler's "Total Eclipse of the Heart." The Voice sent home three contestants, including De'Borah Garner — a lesbian who reveled in her androgyny. (In this case, it was De'Borah's coach, Christina Aguilera, who gave her the ax — but it was the audience vote that put her on the chopping block.)
De'Borah was, hands down, one of the best competitors on The Voice, consistently winning over the coaches and the crowd with her soulful takes on snogs like Train's "Hey, Soul Sister" and The Fray's "You Found Me." And while Brock certainly wasn't the best contestant on The X Factor, he was far from the worst. In the same week when three states — Maine, Maryland and Washington — approved same-sex marriage by popular vote, we have to ask: Why were Brock and De'Borah among the first to go?
The Voice: Who should make the Top 12?
For Brock, the answer is easy. "I think that the gay thing could have had some influence on the voting," Brock said on a conference call Friday. "There's a good portion of America that still thinks being gay is wrong. ... But, you know, I was prepared for that and I don't regret at all being me."
De'Borah, however, disagrees. "Of course not," she tells TVGuide.com, when asked if she thinks her sexual orientation had anything to do with her low number of votes. "America loves me. I know this. I know this, from the crowd's reaction all the way to how my inbox is right now on Twitter and Facebook. ... I doubt it. I highly doubt it."
Both said that they were grateful to the shows for allowing them to be themselves. According to Brock, even after the goosing incident, no one from the network or the show told him to take it down a notch. "I really appreciate X Factor for never asking me to do that," Brock said. "The show itself was always encouraging of me being myself. ... No one ever said I was too gay or needed to tone it down, thank goodness."
And from her blind audition, De'Borah has spoken openly about struggling to find acceptance within her church and community. (Though her parents are 100 percent supportive, they are also both preachers.) Nevertheless, she decided to get the question on everyone's minds out of the way during her first appearance on the show, when she said memorably and matter-of-factly, "Boom, I'm gay."
"Coming to The Voice was like turning a new leaf," she tells TVGuide.com. "I wanted to be myself, without restrictions. Sometimes I kind of felt like I had to blend in, but when I came to The Voice, they accepted me for who I was, so there was no reason to hesitate or have restrictions or restraints to who I was."
The X Factor: Who got cut from the Top 13?
Of their overall experiences, both Brock and De'Borah say they were overwhelmingly positive. (For the record, Brock said he now views teen Carly Rose Sonenclar as The X Factor's frontrunner, while De'Borah said she's backing Bryan Keith.) "The Voice was the biggest platform I ever had in my life and I'm super-thankful," according to De'Borah. "And with all the fans gained, and all the love and support and exposure, I'm headed to the Grammys. I'm just going to continue to work to get there. It was a hell of a stop. I'm so appreciative." As for Brock? "This has been fabulous," he said. "I would have never had the opportunity to grab Mario's a-- like that, and I am so glad I did."
So, what do you think? Did "the gay thing," in Brock's words, play a role in his and De'Borah's ousters this week? Or was the audience just not feeling their singing styles? Sound off below!


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June / July 2012
My original intention was to have this issue address higher education among Christians. But since there were a number of concerns expressed about David Noe's article "Is There Such a Thing as Christian Education?" in the April OSO, it turns out that the title of the current issue has been slightly changed. I considered the title "Education: Christian or Otherwise," given the range of the offerings in this issue.
Benjamin Miller has written a thoughtful response that fundamentally disagrees with Noe. Noe in turn has been given opportunity to reply to this response, as is the custom of this journal. My editorial "Education, Natural Law, and the Two Kingdoms" seeks to frame the discussion to help readers understand the wider context and my position on publishing the Noe article to begin with. I am grateful for the level of discussion carried on by Miller and Noe. I believe that this is just what the important larger topic of the relationship between Christ and culture needs over the coming years and even decades. While I do not want OS to become a debate forum, I do think that it serves us well if on occasion we engage in such exchanges.
I hope to have a number of articles over the coming years exploring the contributions of Christian institutions of higher learning. So in this issue Robert Tarullo reflects on the relationship Geneva College has had with the Orthodox Presbyterian Church. This is a well researched piece. Then James Gidley critically analyses the well-known classic Frankenstein—probably best known through cinema. Gidley explodes three myths and demonstrates Shelley's concern with the relationship of technology to our humanity.
Finally, Darryl Hart reviews The Anointed: Evangelical Truth in a Secular Age, by Randall J. Stephens and Karl W. Giberson. It seems that the authors need to apply their critique of depending on experts to their own enterprise.
Copies of the print edition (2011) of OS should be arriving shortly.
A new set of updated indexes, covering through December 2011, should be posted shortly. Should you notice a typographical or other sort of error, please inform me. Thanks to John Muether for his skillful indexing given as a gift to OS.
Blessings in the Lamb,
Ordained Servant exists to help encourage, inform, and equip church officers for faithful, effective, and God glorifying ministry in the visible church of the Lord Jesus Christ. Its primary audience is ministers, elders, and deacons of the Orthodox Presbyterian Church, as well as interested officers from other Presbyterian and Reformed churches. Through high quality editorials, articles, and book reviews we endeavor to stimulate clear thinking and the consistent practice of historic, confessional Presbyterianism.
The entire issue is available in the following formats: PDF ePub and Mobi
|© 2020 The Orthodox Presbyterian Church
Chaplains and Military Personnel


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A Celebration They Never Thought They'd Have
Photo credit: Jessica Holden Photography/Moment/Getty Images
Owen and Emmett Ezell were born just over a year ago on July 17, 2013. Their birth was a remarkable one, not only because they were twins, which is always neat, but they were conjoined. Now, a year later, they went back to the hospital where they were successfully separated to celebrate their first birthday.
Separation surgery at 6 weeks old
The boys were joined at the chest and shared several organs, and the high-risk surgery to separate them happened when they were just 6 weeks old. The surgery, which took place at Medical City Dallas Children's Hospital, was successful, and the happy mom and dad returned there to celebrate their big day with the staff that helped their boys through the tough time.
The twins had graduated from live-in rehab just a month ago and have been at home since, where their parents report they are thriving. One boy is just about to start crawling, and his mom said that once that happens, the other shouldn't be far behind.
They are both still receiving nutrition through feeding tubes so they were unable to eat their birthday cake — but their parents were happy to report how well they are doing, and they shared their gratitude with the team that operated on and cared for their boys.
I did a little searching on the twins and found a blog that their mom is keeping. It's beautifully written and gives a lot of insight into the struggles this family has endured, as well as the happy moments. Their boys are beautiful and have been a welcome addition to their home, and it shows in their family's smiles.
More babies in the news
Mom missing part of her heart has a healthy baby
Jeff Bauman, fiancee welcome baby girl
Mom catches 6-year-old singing lullaby to newborn brother


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Goya y Lucientes, Francisco José de
Goya y Lucientes, Francisco José defränthēs´kō hōsā´ ᵺā gō´yä ē lo͞othēān´tās [key], 1746–1828, Spanish painter and graphic artist. Goya is generally conceded to be the greatest painter of his era.
Sections in this article:
The Columbia Electronic Encyclopedia, 6th ed. Copyright © 2012, Columbia University Press. All rights reserved.
See more Encyclopedia articles on: European Art, 1600 to the Present: Biographies


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(CNN) - Amazon will start donating some of its unsold products instead of trashing them.
The company said it will start donating the items that did not sell or that have been returned.
It will be done through a new program called "Fulfillment by Amazon Donations," which will operate in the U.S. and Britain.
Amazon will roll out the program next month.
Until then, third-party sellers can choose whether they want unsold items returned to them or thrown away. The new program gives them the option to have the items donated.
Copyright 2019 CNN. All rights reserved.


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Born for the Hills! A Review of the Rivendell Sam Hillborne
I have owned my Rivendell Sam Hillborne ("Graham Greene") for 6 months now, and have ridden it for 1,800 miles. It is time for a review. The short version is: "I love it. I love it so much!" For the long version, read on.
I received a Rivendell Sam Hillborne frame as a holiday gift in December 2009, purchased from Harris Cyclery in West Newton, MA. We were not yet comfortable building up a bike on our own, so the build was done at Harris as well. It took me a few months to save up for the components, and the bicycle was ready in the end of April. Note that Harris Cyclery was not a sponsor at the time, and that everything in relation to this bicycle was a standard purchase.
My choice of build for the Hillborne was informed by test-riding a floor model in my size. Since I had no real experience riding a roadbike at that point, I mostly went with recommended specs. These included a 3x8 drivetrain, Sugino cranks, Nitto Noodle handlebars with Silver bar-end shifters, and a Brooks B17S saddle. My 52cm frame was built for 650B wheels and cantilever brakes.
The three things I specifically chose for this bicycle were handbuilt wheels with dynamo lighting (see details here), Grand Bois Hetre tires (see review here), and Tektro short reach brake levers. The discovery of these brake levers was crucial for me. One thing that had hitherto prevented me from riding bicycles with drop bars, was my inability to squeeze the brake levers - especially from the hoods. I have small hands and I have damaged nerves in my hands. The combination made squeezing this type of lever impossible. When I described the problem to Elton at Harris Cyclery, we went through different brake levers to see whether any existed that I was able to squeeze. The Tektro levers were it and I am extremely happy with them. Elton also showed me some methods of hand and finger placement that work well for me and do not send electric currents through my fingers. I cannot stress enough what a break-through this was in terms of understanding why I was having problems riding with drop bars before.
Renaissance Bicycle (a sponsor), an Ostrich handlebag bag from Velo Orange which I use on long trips,
here for my initial review of them).
chainstay protector. This product is great for preventing the paint on the right chainstay from getting nicked by the chain slapping against it when the bicycle goes over bumps - which began to happen to my Rivendell within the first few rides I went on.
handlebars quite high, so that I could get used to the drop bars. The Hillborne has what I would say is a long top tube, and I have a short torso - so the degree of lean this placed me in required some adjustment on my part.
I love pretty much everything about this bicycle and find it difficult to muster up any words of criticism. It may be worth noting that some dislike the slight upward slope to the top tube on the Hillborne, but I have no problem with it. If I have to find something bad to say, then maybe it's that the paint seems to be a bit delicate - but then I am used to powdercoat, and it's just a fact that liquid paint is easier to nick. I am equally happy with my choice of components - perhaps with the exception of the Shimano Deore rear derailleur, which I have managed to bang up pretty badly in the course of ownership. Next spring, I may replace it with the Shimano XT "Shadow," which seems more immune to abuse. Otherwise, everything is perfect.
track bike I rode in Vienna and to the Italian racing bike I subsequently built up as a fixed gear. Once I learned the skills on the Rivendell, I felt comfortable on other types of roadbikes as well - but I would not have been able to learn on them.


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(Phoenix, Ariz. – April 30, 2004) Attorney General Terry Goddard today warned seniors to be on the lookout for official-looking mailings from private companies promoting "Medicare-approved" discount cards. The official Medicare prescription drug discount cards will not be available until next week. Reports have surfaced that some private companies are attempting to sell fraudulent cards purportedly approved by Medicare.
"Unfortunately there are many out there who prey on the senior population," Goddard said. "If anyone has been contacted about purchasing a Medicare-approved card, ignore the solicitation and report it to my office."
The Medicare-approved discount cards will become available on May 3, and will be effective on June 1. All discount cards approved by Medicare will carry a "MEDICARE APPROVED" seal. This discount card is part of the Medicare Reform package adopted by Congress in December 2003. There is a list of Medicare approved prescription drug card sponsors available online at www.medicare.gov. This Web site also contains other valuable program information. If you do not have access to the Internet, please call toll-free1-800-633-4227 for this information.
The card will cost no more than $30, and will be available to all seniors eligible for Medicare Part A. The cards may be purchased beginning on Monday and may be used to obtain discounts between 10 and 25percent on prescription drugs. Additional benefits are available for lower income seniors.
There are legitimate prescription drug discount cards currently available that have not sought approval from Medicare and may save consumers money. Consumers should carefully look at the benefits offered by these cards if considering one not approved by Medicare. Some may deceptively claim to be Medicare approved when they are not. Seniors should ultimately choose the card that is best for them by taking into account the different features of each card.
Please contact the Attorney General's Office with questions or concerns, or if you know someone who has been the victim of fraud call:
Phoenix Office Of The Attorney General
Tucson Office Of The Attorney General


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Beautiful Bend - Boogie Motion | LINK TWO
Beautiful Bend - Make That Feeling Come Again | LINK TWO
Beautiful Bend - Ah-Do It | LINK TWO
I recently got an email suggesting this album, so I figured now would probably be a good time to pull this one out.. This project is probably one of my favourite things ever done by producer Boris Midney. Midney's otherwise known for other disco projects such as Festival (the name under which he released the infamous "Disco Evita" album), Caress and most prominently USA-European Connection among others. The Beautiful Bend project was to be his second disco release after the first USA-European Connection album.
Born in Soviet-era Russia; in August of 1964 while in Tokyo, Midney and fellow musician Igor Berukshtis would leave their Soviet vaudeville-style group and defect to the U.S. Embassy. Midney and Berukshtis would then be known as the first Russian Jazz players to defect to the west. Once in the US, they would form the Russian Jazz Quartet, who would release one album, "Happiness" in 1965 on the Impulse! label. Apparently the album was passed over at the time and still remains so..
Midney would later reinvent himself in the late '70s as one of the Euro-disco auteurs. Though firmly based in the US by this time, the sound of his productions are perhaps the Euro-est of all the Euro-disco producers. Others like Costandinos and Moroder would draw from funk, rock and R&B influences from time to time; Midney, at least at his most prominent, was firmly based in classical, orchestral, and even jazz influences with a very European melodic sensibility. So much so that Midney's appeal is often completely lost, his work even reviled among many R&B disco purists. That aside, his unabashedly grand, orchestral and at times esoteric European style is a large part of his genius. Just in how he was able to approach disco with a completely, in some cases radically different perspective and make it translate. Probably one of the ultimate examples of the diversity within disco music in the late '70s..
The opening track, "That's The Meaning," is nothing short of heavenly. With those crazy string effects ushering you into a darkly dramatic build up right up until the vocals come in with those few, simple, euphoric words.. "That's the meaning, that's the feeling, that's the joy good loving brings.. It's so real I could feel, I could touch, if I could.." Nothing sums up the feeling, the almost affirmative quality of the song better than that... "That's The Meaning" later segues into "Boogie Motion," which is probably the lightest track on the album with a real playful quality to it, particularly in those vocals and instumental passages towards the end.
From what I've read on forums and such, Side One ("That's The Meaning," "Boogie Motion") was the side that got the most club play, but Side Two (or as they call it on the album, the "Continuation of Side One") is probably the favourite of many listeners of the album. Listening to "Make That Feeling Come Again" it's not hard to see why. With it's dark beginning and the gradual, epic build up to those beautiful, heavenly melodies particularly towards the middle.. That middle part is probably the best part of the song. It's not an overblown peak, but one that's understated, simple and melodic. It mostly consists of a beautiful, layered piano and string combination that can probably be described as blissful perfection.
The album ends with "Ah-Do It", a dark, hypnotic, almost paranoid track with some amazing effects and powerful passages and transitions.
While his sound was unique, there is still a definite disco aesthetic in it, the lyrical themes and minimal female vocals, layered strings, tempos etc.. The rhythmic aspect is also there, albeit not as emphasized and in a groove that is much more esoteric than straight ahead funky. Truth be told, at times it almost comes across as something that is probably easier to listen to than to dance to. There's probably no better way to really absorb it than just simply listening and appreciating the layered melodious quality of the music. That said, I'd love to hear a DJ include these songs in their live set. I can only imagine how an epic track like "That's The Meaning" or even "Make That Feeling Come Again" would have translated on to a dancefloor in one of those early morning hours.. With those larger than life swirling, sweeping orchestral passages and amazing effects on an amazing sound system, the right audience, combined with whatever the drug du jour was at the time, it must have been quite the experience...
Almost and even slightly avant-garde in places, it's no wonder there are many people who either love it or hate this album, and much of Midney's work for that matter.. Whatever the case, Midney, particularly on this album really does take the whole idea of orchestral disco to another level, one that is highly atmospheric and (at least in this case) a little less conceptual. Midney and his work are sometimes referenced as the precursors to trance. I'm probably not knowlegable enough to espound on that comparison, though Midney himself certainly seemed to acknowledge it. In 1999 he'd release an album called "Trancesetter," (so far his last album) which I haven't heard yet, but which apparently combines elements of trance with some of his classic orchestral disco style. It was released at approximately the same time in which he reissued much of his work on CD through his own label on a series called "The Boris Midney Masters" with the "Beautiful Bend" album included. "Trancesetter," the "Beautiful Bend" reissue and all the others in his "Boris Midney Masters" series have been out of print now for several years, but the CD reissue is highly recommended for anyone who likes this album. It's in somewhat high demand these days, probably the most sought-after of his "Boris Midney Masters" series, but there are still copies to be found on Amazon.com and on eBay once in a while.. I'm not sure what Midney has been up to in these last few years. He still has an official website up called MidneyMedia (www.midney.com) detailing a few projects in progress, though I'm not sure how up-to-date it is. That aside, Midney is one producer who's work I'm really looking forward to hearing more of..


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Chiefs Sign 2 Safeties, Release 2 Defensive Backs
KANSAS CITY (AP) - The Kansas City Chiefs have signed free agent safeties Quintin Demps and Malcolm Bronson and released safety Justin Glenn and cornerback James Rogers.
The Chiefs announced the moves before the start of Wednesday's voluntary workout.
Demps played for new Chiefs coach Andy Reid while both were in Philadelphia from 2008-09, and spent the past three seasons with the Texans. The former fourth-round draft pick has 61 tackles, three interceptions and one fumble recovery in 48 career games.
Bronson went undrafted out of McNeese State, where he made 230 tackles in 40 career games.
Glenn was trying to make the Chiefs after playing in 40 games over four seasons for the University of Washington. Rogers played in 46 games over four seasons at Michigan.


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A feisty President Obama used his State of the Union address Tuesday night to double down on the progressive principles that won him a second term, challenging the GOP to come along for the ride.
The president outlined a sweeping list of political priorities that touched on many worthy goals — making preschool available to all children, expanding green energy development, comprehensive immigration reform, gun control and a broad infrastructure repair program.
"It is our unfinished task to make sure that this government works on behalf of the many and not just the few," the president said. "That it encourages free enterprise, rewards individual initiative, and opens the doors of opportunity to every child across this great nation."
Unfortunately, the president spent relatively little time on the problem many Americans say they find the most troubling — the federal debt.
Yes, he took it on. He acknowledged how spiraling health care costs are driving deficits, and talked about how the nation "must embrace the need for modest reform" of Medicare.
However, the recommendations he offered were fuzzy statements such as asking "more from the wealthiest seniors" and changing the way the government pays for Medicare.
Then, the president pivoted to what he said was the need to close loopholes and deductions for the wealthy and well-off.
If only the nation's budget problems were so easily solved. Democrats, led by the president, must come to the table with meaningful entitlement cuts as a part of a balanced approach to get the country on firmer financial footing.
As the cold, hard math of the bipartisan Simpson-Bowles commission showed, the path there involves additional revenues, but also more painful reductions than Democrats favor.
To be clear, there were many laudable ideas and touching moments in the president's address — so many it was hard to keep track.
The president's vision of government was one poised to nurture a nation recovering from wounds inflicted by the economic meltdown.
It was one of compassion for hard working Americans who are struggling, unable to get ahead.
But this vision for prosperity, however admirable, cannot be supported by a government with record debt that cannot even agree on a plan to heal itself.


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Diablo III's new "Paragon" system was brought in to give "maxxed out" players some more stuff to do. It's been working for most, I guess, but for Alkaizer the well has once again run dry, because his Barbarian character has managed to hit the game's new ceiling.
As you'd expect, it took a lot of furious clicking. For reference, to get to regular ol' level 60, you need 23 million XP. To get to a level 100 of the Paragon system, you need over 3 billion XP.
If that's not making you feel inadequate enough, check out his armory page. And look at his weapons.
Alkazier [Diablo III, via PC Gamer]


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A favorite of club-goers for 20 years and counting, Peat Moss and the Fertilizers is one of Long Island's most popular wedding bands. Peat Moss brings an energy and enthusiasm that has made them a top party / club band, and with hundreds of weddings under their belts they also bring the experience of seasoned veterans to the wedding industry. Peat Moss has its finger on the pulse of today's music while also being well-versed in your traditional favorites.
BUT BE WARNED: Peat Moss and the Fertilizers is not your typical, boring, old-fashioned wedding band. They represent the next generation of wedding bands for a new generation of brides and grooms. With an extensive song list and a DJ by their side (which they supply at every event), Peat Moss will keep the music flowing non-stop throughout your party and cater to exactly what you want to hear on your special day.


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Crabgrass, Johnson grass, dandelions—such weeds can overcrowd lawns and pilfer air, water and nutrients that desirable plants need to survive and maintain a healthy appearance. Unchecked, weeds can completely dominate these plants, turning what could be a beautiful and verdant lawn into a wasteland of unsightly weeds. Keeping this in mind, it's no wonder why so many clients are eager to pay qualified experts to swoop in and save their lawns from utter weed-spangled catastrophes.
And what better way to curtail weed growth than by stopping them before they've had a chance to break through the turf's surface? Such is the philosophy behind pre-emergent controls. "By eliminating the weeds, we're limiting the competition between them and the plants," says Bryan Thompson, vice president for Pest Option, Anaheim, California. "The best way to get rid of weeds is to eliminate them when they're still seeds."
Pre-emergent control takes a very simple approach to reducing weeds with the use of chemical or biological herbicides (though they're typically chemical). You create a barrier—or a weed prevention zone—in the top one to two inches of soil that prevents weeds from breaking the surface. This process falls under the umbrella of integrated pest management (IPM), a multiplestep program that promotes the judicious use of fertilizers and weed and insect control as it pertains to the health and appearance of turf.
"With IPM, you're looking at the overall needs of the property from the get-go and then applying herbicides on an as-needed basis," says Mike Sisti, marketing manager for Lebanon Seaboard Corporation, Lebanon, Pennsylvania. "You're also integrating cultural practices to promote the turf. Herbicides play a big part in IPM, but you're also going over the property and spottreating exactly where the weed problems are."
Integrating weed control into your company's services can be a great way to bring in extra revenue, as well as build new relationships with customers who want to clean up their lawn. Preemergence is most likely your safest bet in making a good impression. "The most effective control for weeds is pre-emergent, dollar for dollar," says Thompson.
There's a wide range of herbicides and IPM practices out there. Chemical herbicides seem to be the standard for today's industry, but biological herbicides such as corn gluten meal can be used as well. It's all a matter of knowing what your client expects. What kind of lawn do they want? What are their opinions so far as chemical herbicides go? And how do you continue to ensure a vibrant and healthy lawn after the pre-emergent controls have been applied? This article should help put things into perspective.
Chemical herbicides
Many factors need to be considered before choosing which chemical to apply. There's a vast array of herbicides on the market, all of which are made to treat different kinds of plants in different kinds of weather. "There are a substantial number of herbicides coming into the market, and they're constantly changing," says Thompson. "The principle thing people need to do is research the material and know what they're doing with it."
Once you've pinned down the type of herbicide you'll be using, you'll want to know how to apply it. Again, depending on the type of herbicide you'll be using, application procedures can vary. Always read the label on the side of the product to learn how it's to be applied. By rule of thumb, herbicides should be bonded to the soil twice a year: once in the winter and once in the spring. Determining exactly when it's time to cover the turf with herbicide is dependent on the region you're in and how warm it is, but try to shoot for about two to four weeks before the weeds begin to germinate.
For Mark Urbanowski, senior marketing specialist for Dow Agro-Sciences, Indianapolis, Indiana, weeds will begin to sprout at about 50 to 55 degrees. "That's the temperature where crabgrass and many other weeds start to germinate," says Urbanowski. "So we'll spread the herbicides before the soil gets to that temperature." Once the temperatures warm up enough, the herbicides will take effect and create a barrier to stop the weeds.
Every region is different from the next and depending on where you are, you might face different standards on when it's right to lay down herbicide. Again, much of this comes down to reading the instructions on the side of the product and following them carefully. Talking to other weed control practitioners in your area and learning their procedures can't hurt either. Herbicides can be applied by spraying with liquid, spreading with fertilizer or in granules. Then it must be watered in to create an effective weed prevention zone. Afterwards, you should be mindful not to puncture the soil, as this will create a space for weeds to grow through, thus defeating the whole reason for putting herbicide there in the first place.
Although the vast majority of chemical herbicides are perfectly safe for desirable plants and people handling the products, you must still exercise caution when using them. If the surface water runoff of the product makes its way to any nearby streams, it can contaminate the water. In general, though, chemical herbicides are safe for both the user and the environment. "Sometimes there are negative preconceptions that go with chemical herbicides," says Sisti. "But that's just not the case. When performed by a trained professional, they can really complement a smart ergonomic program."
Chemicals aren't the only way to go when using herbicides. Biological herbicides are a popular alternative, especially in eco-conscious regions such as California, Oregon and Washington, where the word 'chemical' tends to spark uneasiness. Not all homeowners are comfortable dappling their lawns with products that were made in a laboratory, whether that product poses any real risk or not. A biological herbicide might be just the environmentally- friendly alternative these homeowners are looking for. Likewise, public places such as schools or parks are hot spots for biological herbicides. "In terms of business, there are a certain percentage of people out there who don't want chemicals near their house or their kids," says Nate Elfner, owner of Elfner Landscape and Organic Lawncare, Delaware, Ohio. His company specializes in organic lawn care, using the most natural products possible. "I'm providing a viable service to those people. It's a largely untapped market right now. I mean, these people are already buying organic food and milk and things. When they realize that they're having their lawns chemically sprayed, they see what we have to offer is a nice alternative." Corn gluten meal is the most widely used biological herbicide.
A byproduct of corn that's commonly used as an animal feed, corn gluten meal is also a fast-acting pre-emergent control. As an herbicide, it releases nitrogen onto the turf, helping the grass to grow thicker and crowd out weeds. It stays effective for eight to 10 weeks. "I do one application in mid-April and then again in late August in time for autumn," says Elfner. However, corn gluten doesn't provide as much control as chemical herbicides. "It can be considered an herbicide, but corn gluten only has 40% control," claims Cheryl Wilen, area IPM advisor for the University of California, San Diego, California. "It's pretty good for crabgrass and dandelion control, but a lot of chemical companies aren't satisfied with only 40%."
Corn gluten meal is also considerably more expensive than chemical herbicides. Those looking for cost-friendly biological alternatives might want to consider organic mulching. Mulch is a popular weed control for areas surrounding tree trunks and flower beds. A two- to three-inch layer should be all you need to keep the weeds from sprouting. Compost can be mixed into the soil, improving the health of desirable plants and making them more competitive. This gives desirable plants more leverage to edge out weeds. In addition to pre-emergents, there are post-emergent chemical herbicides. These products are sprayed selectively onto weeds that have already germinated, killing them—but that's another article for another time. For those in favor of biological herbicides, Sarritor, a Montreal, Canada-based pest control company, is currently developing a post-emergent product called Sclerotinia minor, a fungus that can kill broadleaf weeds. "If this product is introduced in the States, it could be the missing link for finally having a post-emergent control that's organic," says Elfner. One thing landscape professionals should keep in mind is that weed seeds can stay dormant inside the ground for much longer than most people imagine. "There's been lots of studies done where they've excavated seeds in the soil and they can still germinate," says Urbanowski.
"They'll stay underground for hundreds and hundreds of years." Having an efficient program set in place is a great way to curtail weeds, but you can't just apply herbicides and fertilizers once and expect the lawn to keep its pleasant appearance a year down the line. Just like your equipment, if you want to keep things in good shape, regular maintenance is in order. A good contractor should be inspecting the integrity of the lawn regularly, checking for weeds, pests, gaps in the turf, etc.
This way, whatever problems are spotted can be addressed before they become serious. Proper mowing, fertilization and aerating on an annual basis are key when it comes to maintaining healthy turf. Effective irrigation also plays an important role in weed control. Good water distribution will increase the thickness of the turf, creating a continuous sward to protect against weeds. Drainage is of particular significance. "Always watch where your system is draining," says Wilen.
"A lot of times, areas over-saturated with water are where you'll find weeds coming up." What should perhaps be kept in mind more than anything else are your customers' needs. Some customers are perfectly happy so long as they can't see weeds sprouting from afar. Some might even enjoy the sight of a dandelion here or there. Others might be very picky. "What's the definition of a weed?" asks Sisti. "A weed is any type of unwanted plant. But it's all subjective in that respect. Our job is to figure out what those unwanted plants are."
It's up to you to determine what it is your customer expects from a lawn and to follow those expectations accordingly. From there, it's just a matter of keeping those pesky weeds in check.


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Thanks to Petar (Versif) for hosting an enjoyable evening at his home (with hugely enviable games room!)
Really nice to meet you all and put faces to names.
Lots of conversation covering everything from local railways and 15" prototypes to our own confessionals on entries to the hobby.
Also some comparison with the wargames hobby (I hope Colin and David didn't feel too marginalised there!)
Petar showed us plans of his planned layout which looks very promising, Colin brought some really nice On9 stuff he's been building, very fine.. David's Lister looks great as do idea / plans for the layout.. and everyone was very kind about my figures and bodgejob locos
Loads more discussed and looked at.. I've come away with renewed Gn15 fervour and more ideas..and despite wanting desperately to finish off my next two figures tonight, I've lost my only cocktail stick !! and I'm lost without it!
No mention was made of a joint effort layout - were we too scared to bring that up ?
Look forward to seeing progress on everyone's projects in the near future.
Thanks again to Petar for your hospitality.


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Osprey Packs will be expanding its local headquarters and relocating its distribution center to Utah in 2015, the company announced last week.
"The decision to relocate our distribution function to a transportation hub, such as the Wasatch Front, is an exciting and necessary move for Osprey," said Tom Barney, CEO of Osprey Packs, in a written statement. The Wasatch Front is the metropolitan area of Utah, which includes Salt Lake City.
The company has been growing rapidly in recent years and in 2006 the started adding supplemental warehouse space in and around Cortez, said Barney.
The company plans for the new consolidated distribution center, which will be staffed by 20 people, to open by mid-2015. Some staff members will be relocating from Colorado, and some will be hired in Utah.
As part of the expansion, the company plans to convert warehouse space into offices in 2015, which will allow all the employees, who are part of headquarters to work in one building. The company also hopes to add a fitness center and some form of kitchen, which could allow local restaurants to serve meals for employees on a rotating basis.
Osprey employs 74 people locally and hopes to fill four positions soon. It also may add staff members to headquarters as it continues to expand, he said.
Moving the distribution center to Utah helps solve the company's space constraints.
Currently, the company's storage is spread over five warehouses, three in the industrial park and two within city limits.
Osprey also maintains a product development office in Ho Chi Minh City, Vietnam, near the factories where they manufacture their products and a design office in Mill Valley, Calif.
Barney said the company plans to keep headquarters in Cortez.
The owner and founder of Osprey, Mike Pfotenhauer, and his wife, Diane Wren, also plan to move back to the Dolores area from California, he said.


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Lil' Wayne - Rollin Freestylerate me
G5 sitting on the runway
This for my dawgs locked down all day
Money, power, respect: 3 the hard way
I put some real niggas on their feet, boy
So they'll kill anyone for me, boy
Yeah, YMCMB boy
Young Tunechi fresh to deah
Rest in peace, boy
My Gat bang, your hat hang
I ride of with Mack Maine
I drink Patron straight
You niggas keep that champagne
My pa is the Birdman
I'm rich as a white man
I come to your show and kill you
And your hypeman. We roll in
Let's roll out, my bitches
Don't hold out. They got Marley G
I gotta burn my lil bro out
Let my dreads grow out
My bitch got a blow out
Mi casa, su casa. My house is
A ho house. Only fuck with
Real niggas. Polo, fuck that Hilfiger
Yeah I'm on a pill nigga
Feed you to my little niggas
Shout out to my big homies
Fifi and T-Streets
Scope on that aK make me take a sneak peek
T, roll another one
Razor blade on the tongue
You ain't ever seen this watch
Nigga, this a one in one
You niggas is honey-buns
Your girlfriend's a ton of fun
Chopper with a drum, muthafucker
Get a drummer son
Cut that like my blunt is done
Suck a nigga's dick or something
Put that pussy for me then wile out
And give my nigga's some
I'mma do my thing, I put that
On Nicki Minaj, I need a bad redbone
To come give my dick a massage
I'm talking big money
I'm talking heavyweight
I cut down on the syrup
Now I'm in better shape
I'm from New Orleans nigga
Where you ain't ever safe
Fuck with me, I drop you off
In front of Heaven's gates!
OK, jump off a building,
Jump out a window,
Smoke like a junkie
And fuck like a nymph o!
Drink like a goldfish
That's right, you know this
Hold up: click-clack
OK, I'm reloaded.
Fuck with Lil Tunechi
I'm good on Gucci
Wild as Ryu
I hit you with that Hadouken
My money too long, nigga
My weed too strong, nigga
Fuck everybody, Im in my
Own zone nigga. And every time
You see me I'm wet and I'm rolling
Tunechi rest in peace, fresh to death
And I'm rolling. About to fuck a bitch
I just met cause she rolling
Nigga we rolling, nigga I'm rolling
Gotta keep a title, I'mma sweat cause
I'm rolling. Pouring out a bitch
Nigga's neck, cause I'm rolling
Damn ma! I ain't come yet!
Cause I'm rolling. Bitch, I'm rolling
Young Mula, baby. Sorry for the wait

Thanks to adrianna
Thanks to sapphireflamz for correcting these lyrics


text:
A strikingly beautiful building and memorial in one: the Church of Our Lady in Dresden is more than just a house of God. It is a place for meeting and reconciliation, and is considered a symbol of peace the world over.
When the Church of Our Lady fell victim to the flames during the devastating bombing in the night of 13 February 1945, nobody imagined that another religious establishment would stand in its place 60 years later, true to its historic predecessor. The light and dark stones in the façade reveal that the Baroque domed building – the most important one of its kind to the north of the Alps – arose from the rubble. Angels' heads on either side of the altar and an eight-bell peal, which was used to signal the start of services between 1734 and 1925, are all witnesses to the church's past.
The Church of Our Lady was consecrated in 2005, after 12 years of construction. Concerts with renowned artists are evocative of the period around 1736, when Bach played the organ designed by Andreas Silbermann here. Church music still accompanies the services to this day, which are also held in English once a month. Those simply wanting to find themselves will have plenty of opportunity to do so in the church, in the Room of Silence beneath the church or while staring into the distance from the 67 metre high viewing platform offering fantastic panoramas of Dresden and the surrounding area.
Opening hours: open church; public access usually on weekdays from 10am to 12pm and 1pm to 6pm; weekend opening hours depend on the events held. For precise times, visit: www.frauenkirche-dresden.de/Veranstaltungen
Entry: free
Nearest train station: Dresden
Tours of the church; varied programme of music events and concerts, organ concerts
Tālummaiņa jūsu pārlūkā ar divām ērtām taustiņu kombinācijām:
Tuvināt: +
Tālināt: +
Lai saņemtu atbalstu no pārlūka izstrādātāja, noklikšķiniet uz ikonas:


text:
I'm 70 and regularly do cardiovascular and weight-training exercises. Now my doctor wants me to add balance exercises to my routine. Why?
You've asked a good question, and it has a simple answer: Poor balance can cause falls. Every year, one in three adults 65 or older falls at least once. Especially in older people, falls can be serious. More than 90 percent of hip fractures result from falls. Falls also often lead to fractures of the spine, forearm, leg, ankle, pelvis, upper arm and hand. These injuries can undermine your independence. Hip fractures, in particular, also can increase the risk for early death.
Balance is the ability to distribute your weight in a way that enables you to hold a steady position or move at will without falling. From the moment we sit or stand up as infants, gravity is always pulling us downward, tending to cause us to fall. Our ability to balance keeps this from happening — most of the time.
Our daily balancing act requires multiple different body systems to be constantly working together. These include the central nervous system (brain and spinal cord), the vestibular system (brain and inner ear), the visual system (brain and eye) and a vast web of position-sensing nerves. Muscles and bones are pressed into service as well.
Balance is like muscle strength: The more you use it, the less likely you are to lose it. Worse, it can become a vicious circle. You feel a little unsteady, so you curtail certain activities. If you're inactive, you're not challenging your balance systems or using your muscles. As a result, both balance and strength suffer. Simple acts, such as strolling through a grocery store or rising from a chair, become trickier. That shakes your confidence, so you become less active … and so the vicious circle continues.
Good balance, by contrast, helps prevent potentially disabling falls. It builds confidence and fosters independence.
It sounds like you're an active person. Most likely, you already engage in some activities that help hone balance. Yoga, golf, biking and tai chi all require some degree of balance. But even people who are not already active can improve their balance through exercise or balance training.
I've posted some beginner balance-training exercises here. They are a good first step toward improving shaky balance and can be done by people of many ages and abilities, including those who are elderly or frail. As your balance improves, you can add challenges to make your balance training progressively harder. For example, try an exercise standing on one leg instead of two.
Even if you are conscientious about doing regular aerobic and muscle-strengthening exercises, if you feel that your balance isn't what it used to be, talk to your doctor or to staff at the gym about learning balance exercises. They could help protect you against falling.


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Did you know that Carrie Underwood and late-night TV host Jimmy Fallon were once a singing duo? And that they specialized in countrified versions of hip-hop songs?
Neither did we.
During her appearance on Late Night With Jimmy Fallon last night, Carrie and Jimmy revealed a few highlights of their past as a pair of and rhinestone- bolo-tie-bedecked country singers who, during their '90s heyday, specialized in the "country rap" (or, as Carrie put it, "c'rap") genre.
Among their repertoire were versions of N.W.A.'s "Straight Outta Compton" (which took some work to make TV-friendly), Dr. Dre's "Nuthin' But a 'G' Thang" (featuring Snoop Dogg), and Digital Underground's "The Humpty Dance."
Check it out ya'll.
OK, so it's not exactly true (all right, not at all true), but it is pretty gosh-darn funny.
Carrie then went on to sing a 'real' song on the program ("Blown Away"). Oh, and there was some other guy from a certain popular movie series on the show as well.
– Kurt Wolff, CBS Local


text: #10: National Tom Sawyer Days -- July 1– 4, Hannibal, Miss. Now in its 55th year, this annual celebration of the works of Mark Twain takes place in the river-side town of Hannibal, where the novelist spent his childhood. Some events are pulled straight from the pages of classic Twain tales, such as the fence painting competition, in which contestants try their hand at whitewashing a fence in the fastest time possible.


text:
By The Canadian Press | The Canadian Press 14 hours ago
LONDON, Ont. - A 10-year-old boy rescued in urine-soaked pyjamas from a squalid bedroom where he had been confined for up to two years expressed hope, authorities say, that he can now attend school.
After receiving an anonymous tip, authorities discovered the boy in horrific conditions, locked in a bedroom of his aunt and uncle's house in the southwestern Ontario city.
"There was a lot of garbage in the house," London Police Insp. Kevin Heslop said at a news conference Friday.
"There was a lot of packaging from fast food outlets. In the bedroom specifically there was feces, urine, the bed was soaked in urine, as was the child's pyjamas when the child was found and there was food waste throughout the house."
The boy had been locked in the bedroom for at least 18 months, possibly as long as two years, Heslop said. He may have been out "for a brief period of time" in 2013, he said. The boy was typically fed twice a day, fast food that was left for him to eat, Heslop said.
"The master bedroom had an ensuite bathroom so the child had access to a toilet and shower, however the room in fact the entire house was in squalid condition," Heslop said.
The boy's aunt and uncle have been charged with failing to provide the necessaries of life and forcible confinement. Their names are not being released to protect the boy's identity.
The boy was underweight, malnourished, confused and pale, Heslop said. He had been living with his aunt and uncle since 2010, when the boy came to Canada. He speaks "some" English, Heslop said.
He would not say what country the boy came from, but his parents do not live in Canada and investigators have not yet been able to contact them, he said.
"I don't know if they know," Heslop said.
It doesn't appear as though the boy went to school, he said.
His aunt and uncle also have a biological child, who the executive director of the local children's aid society described as a nine-year-old girl. There is no evidence the couple's biological child was ever locked in a room, Heslop said.
Both children were apprehended and taken into care, said Jane Fitzgerald, the executive director of the Children's Aid Society of London and Middlesex.
"We're now just getting to know this boy," she said.
"I think that we were happy to find out from him that some of the things that he wants to do right away is he wanted regular food and he said the one thing he really wants is to go to school. I think that's a good sign. He wants to re-enter the world."
CAS was involved in 2007 with an incident involving the aunt, a former partner and a teenager, Fitzgerald said. But CAS had never been inside this home before nor had they been involved with this family unit, she said.
Authorities got an anonymous tip from a community member about a child who was reported to be home alone late into the evening, prompting a CAS worker to visit the house Thursday afternoon, Fitzgerald said. Though no one appeared to be home, the worker saw a shadow behind drapery and contacted police, she said.
A teenager who lived in the house next door said she had seen a man and woman and even the girl on occasion, but not the boy.
The house had a playset in the backyard with a swing and a slide, which the girl could be seen playing on occasionally, but the boy authorities found was never seen, the neighbour said.
"We had no idea that he was up there. We had no idea that he was even in that house," the 16-year-old said.
"It seemed like a pretty normal house. We never would have suspected something like that."
Fitzgerald praised the courage shown by the tipster.
"Ensuring a child's safety is a community responsibility, so if anyone in our community have reasonable grounds to suspect that a child is or may be in need of protection, please call us," she said.
"That is how we are able to protect children. We know it is not an easy call to make, but it can save the life of a child."
The case has some similarities to that of Jeffrey Baldwin, a Toronto boy locked for long stretches of time in a cold, fetid room by his grandparents and so severely starved that when he died in 2002, just shy of his sixth birthday, his weight was that of a 10-month-old infant.
In Jeffrey's case some of his siblings, who also lived with their grandparents, were not subjected to the same neglect and abuse. Like this boy, Jeffrey was also not enrolled in school.
Irwin Elman, the provincial advocate for children and youth, noted how the recommendations that came out of the Jeffrey Baldwin coroner's inquest earlier this year stressed that protecting kids is not only the job of children's aid societies, but is "every citizen's responsibility."
Elman sees many similarities between the two cases, but one big difference.
"I think that's important to recognize that in this situation a member of the public, it seems, came forward with a concern and to me that speaks to the recommendations about child protection not being in the sole purview of the child welfare system," he said.
"This person who made the call, who expressed a concern, may very well have saved a child's life."
Written by Allison Jones in Toronto with a file from Diana Mehta.
Some people are just absolute barbarians.


text:
absurdity, ale, art, B.M. Stroud, beauty, Birth of Venus, Botticelli, breath, centeredness, chaos, conspirare, creation, desire, eternity, Feral, Flora, God, HobGob Press, human, imperfection, jazz, Louis Armstrong, love, memories, Michelangelo, nature, order, poetry, Primavera, soul, soulmate, space, spiritual, stream of consciousness, sub-human, Sysyphus, tantra, The Creation Of Adam, The Oracle: Art - Essays and Blogs, time
The thread of Sutra reads west to east in the first line, east to west in the second line, and so forth as the arrows continue to indicate the flow of the thread.
Sutra is about the material of human chaos out of which we thread an order. It is also about how we try to make human, or spiritual, connections that perhaps cannot ever be made except through art—Michelangelo, Botticelli, jazz, Louis Armstrong, poetry . . .
I have the idea of "soulmate" included, as a concept of connecting in a way that can only be imagined.
The words in (parentheses) denote TIME. The words in [brackets] denote SPACE. There are italicized words which denote human EMOTION or feeling, such as "wanting" or "desiring." Denotations of ART are in the font of "Matisse ITC." All other texts are in the font of "Times New Roman." These could be read as minor threads within the larger thread.
I used text size to denote a thread of order out of chaos. The largest size, 20 pt., is for that which we order as a highest being; the 16 pt, for that which is human; followed by 14 pt, italicized, for that which is sub-human in nature, such as "feral," "spiders" or "dogs." The smallest texts, of no particular denotation, are 10 pt.
TOP PHOTO: Louis Armstrong, painted on a wall of Denver, Colorado's Cervantes Masterpiece Ballroom (The Other Side), by Jared Hankins. The building once housed the Casino Caberet, in the famous Harlem-like Five Points area, where beat poets Jack Keroauc and Neal Cassady once reveled to the hip, soul-inspiring "black 'sutras'" of jazz/swing era icons. Photo by S.A. Bort 2012.
Sutra was published by Brandon Stroud of HobGob Press in his previous online magazine for experimental works of art–The Oracle: Art, Essays And Blogs, a part of HobGob Press [http://www.bmstroud.com/hobgob-press.html].
I appear within the chapbook: "god: by 100 poets," published by and available from HobGob Press [see http://www.bmstroud.com/ also]. The poem is in stream-of-consciousness, spoken-word form and documents what one-hundred very different individuals think of God today–a Zeitgeist: "The spirit of the time, the taste and outlook characteristic of a period or generation," as defined by the American Heritage Dictionary of the English Language, 5th edition.
There is much more joy of hip and danceable, experimental art to be found at http://www.bmstroud.com/ and http://www.bmstroud.com/hobgob-press.html. Please visit there–and enjoy! Be sure to check out Stroud's incredible resume, including his work with autism, acting and spoken-word poetry. Also check out his newest, and perhaps most important project, the Poetry Plague Project–a plague of poetry which will span the globe [http://www.bmstroud.com/poetic-plague-project.html].
For similar blogsposts of mine, please see:


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At a time when road safety constitutes one of our daily worries, Clarion offers the opportunity to increase your visibility with a monitor that simultaneously displays the views captured by four on-board cameras positioned on the bodywork.Mini cameras offering maximum performanceClarion's rear vision cameras are ultra-compact, offering maximum visibility with the minimum use of space. Because of their wide angle coverage, nothing will escape you. Their high-resolution sensors ensure the depiction is as close as possible to reality, even in the dark. Now, with no more impromptu overtaking and hidden obstacles, you can drive in complete safety and enjoy easier parallel parking.A 7" monitor with quadruple displayTo combine the output of this on-board camera system effectively, Clarion offers a multi-display 7" colour LCD screen: the CJ7300GA. With four areas on display at the same time, you can achieve a panoramic view of your surroundings, or concentrate on just two cameras if you prefer. Select a reference point for the rear distance to get a better notion of the angle (intervals of 1, 3, 5 or 7 metres). The CJ7300GA monitor also offers the option to display either the regular or reverse image (in the case of cameras positioned to the rear of the vehicle).
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Nathan Smith - September 15, 2019
A Hard Look in the Mirror, "Do You Love What God Loves?"
Heritage Baptist Church September 15, 2019 "A Hard Look in the Mirror, 'Do You Love What God Loves?'" with Pastor Nathan Smith Hbclynchburg.com
More Messages from Nathan Smith | Download Audio
From Series: "The Gospel of Matthew"
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March 10, 2019
The ABC's of the Calling of God
Vernon Smith
February 3, 2019
Sacred Relationships: How Social Media is Destroying Intimacy
Kent Gregory


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text: 15 things your feet say about your health February 26, 2019 2:05 AM Posted: February 26, 2019 2:05 AM iStock/courtneykTo read more about these warning signs, visit https://www.caring.com/articles/18-things-your-feet-say-about-your-health. Show Caption Hide Caption FreeImages.com/Aron BaloghFeet that are really painful to walk on -- Extreme pain along the sides of the feet, in the soles or "all over" can be an undiagnosed stress fracture. Such fractures may be caused by an underlying problem such as osteoporosis. Show Caption Hide Caption iStock/nico_blueFlight attendants also know that air travel can be murder on your skin. They recommend baby oil for keeping your skin from drying out, according to Yahoo Travel. Show Caption Hide Caption FreeImages.com/sarah cazeeFrequent foot cramping -- It can be something as simple as exercise or dehydration, but your diet may lack sufficient calcium, potassium or magnesium if it happens often. Show Caption Hide Caption FreeImages.com/Richard StylesCold feet -- It could be nothing, but cold feet may also be a sign of a thyroid issue, especially in women over 40. Poor circulation may also be to blame. Show Caption Hide Caption FreeImages.com/Chilli DSuddenly enlarged big toe -- It's likely the old-fashioned-sounding disease known as gout, a form of arthritis that's usually caused by too much uric acid. Show Caption Hide Caption FreeImages.com/ana fernandezToenails with sunken, spoon-shaped indentations -- This is often a sign of anemia, which often shows up as an unnatural, concave or spoonlike shape to the toes' nail beds, especially in moderate-to-severe cases. Show Caption Hide Caption FreeImages.com/diego medranoThick, yellow toenails -- A fungal infection such as onychomycosis could be running rampant underneath the nail surface. Show Caption Hide Caption FreeImages.com/Manny ProebsterToes that bump upward at the tips -- "Digital clubbing" happens when the tips of your toes swell to the point that they appear to bump upward at the ends, and can be a sign of serious lung disease, heart disease and certain gastrointestinal diseases like Crohn's disease. Show Caption Hide Caption FreeImages.com/Benjamin EarwickerSore toe joints -- This can be a sign of rheumatoid arthritis, which is often first felt in smaller joints like the toes and the knuckles of the hands. Show Caption Hide Caption FreeImages.com/Crissy PauleyA sore that won't heal on the bottom of the foot -- Yahoo! says this is a major clue to diabetes, as elevated blood glucose levels lead to nerve damage in the feet and minor scrapes or irritations often go unnoticed. Show Caption Hide Caption FreeImages.com/Pierre AmerlynckToes that turn red, white and blue -- Raynaud's disease causes the extremities to first go white, then turn blue, and, finally, appear red before returning to a natural hue in cold weather. Raynaud's is usually not dangerous, but can be a sign of an autoimmune disease in some people. Show Caption Hide Caption FreeImages.com/leagunNumbness in both feet -- Peripheral neuropathy, or damage to the peripheral nervous system, is the likely cause if you can't feel your feet or have a heavy pins-and-needles sensation. Chemotherapy may also be to blame. Show Caption Hide Caption FreeImages.com/dcarson924Being unable to lift your foot up from the heel -- According to Yahoo!, foot drop is a sign of nerve or muscle damage that can originate as far north as your back, shoulders or neck. Show Caption Hide Caption FreeImages.com/laura-sHairless feet or toes -- Poor circulation, usually caused by vascular disease, can make hair disappear from the feet, according to Yahoo!. Show Caption Hide Caption iStock/LisaIsonSummer apparel (worst) -- DealNews says the new summer stock of clothing likely won't see discounts until July, so instead try shopping spring clearance sales, where you can find T-shirts, shorts, sandals and other apparel for cheaper prices. Show Caption Hide Caption FacebookTwitterLinkedinemail